Friday, May 2, 2008

osteopathic instincts

ok, i finally signed up for the blog. sorry it takes me so long to do this stuff... as i alluded to before, i'm kind of in an "i don't wanna" phase when it comes to school. and as a result, my "jaded osteopath" meter is running a bit high these days. i guess i'm just low on energy in this arena. i do believe this is something that ebbs and flows for us over the course of our careers... at least, from what i've seen with the practitioners i know. i'm only now starting to get my act together researching residencies...

interestingly, my enthusiasm to treat patients with my hands never seems to wane. it continues to feel completely natural, applicable, and surprisingly easy to fit into a time-restricted environment. i think that as we develop our manipulative skills over time, the patient assessment process becomes very intuitive. there's no need to do a 'standing flexion test' when you can just look at a patient and tell which SI joint is misbehaving. why take the time to motion test individual vertebrae when you can lay a hand on the patient's back, feel the momentum of the entire spine and the (mal)position of several key ribs and determine that the crucial restrictions are actually coming from their shoulder?

i'm actually pretty mystified as to how this transformation occurred... perhaps you all can comment based on your personal experiences. i worry at times that i am becoming less "scientific" about my approach to patients, but medicine seems to be every bit as much 'art' as it is 'science' in my (limited) experience. i enjoy the opportunity to work as an artist, bearing in mind of course that my work must complement or at least not fly in the face of modern medical science.

but i'm always afraid that patients will leave after a treatment and not improve... i rarely have those doubts when recommending to them more 'traditional' standardized courses of treatment... antibiotics, steroids, and the like. perhaps it is because of the research issue that martha raised. i think it is also in part because of the 'art'. i haven't yet learned to trust my muse in the same way that i trust what i read in my textbooks. this is sad to me, but perhaps understandable, given that i've been in academia for the majority of my life and i've only been involved in osteopathy for 3 years. the more i trust my instincts, the more they grow and the less often i struggle in my approach to patients... with both OMT and 'conventional' methods.

it is still very prominent in my consciousness, however, that i must ask permission to shift into 'osteopathic gear' from my preceptors and lay hands on my patient to heal... not just to palpate the precordial impulse or percuss the liver. i look forward to a time in my career where all my activities as a physician can blend together in a more organic fashion. as i look at residencies, this is something i am trying to keep in mind... it would be nice to find a program that allows me the support and freedom to practice medicine the way i want.


Unknown said...

a quote from the back of one of my old harvard t-shirts:

"I have never let my schooling interfere with my education." - Mark Twain.
I hope that as we grow in our profession, we'll learn to do the same.

Recently, Kelly and I went hiking and we had a toddler in our group. The little dude was in awe of the world around him. He put his hands on this huge quartz boulder, and his eyes and posturing just seemed like he knew. It was almost like he was looking through the rock -- past all of the weird carbon bonds & tightly packed protons that we'd dissect it to be, and was able to see just the essence of the rock. If we jump into the medical jargon, take a look at social smiling, object constancy, even what we call "instinct" in "lower" organisms. There's so much we know about the world that we learn to forget. Osteopathy is amazing because it's so natural. Yes, we have words to describe and quantify our findings now. Still didn't care about these. His writings are filled with "harmony," "God," and "nature." Do we need the science? Absolutely. We need it to quantify, explain, and collaborate. However, in doing so, we can't lose the art (thank you, Kelly), sensory perception, and intuition. Spinal manipulation and quantum fluid mechanics in the body predate osteopathy, and they certainly predate osteopathic medicine. Our job is to connect the science and the art into a meaningful communication that can transcend the social, political, and educational barriers that have joined us all together.

Anonymous said...

Dear Kelly, you're wonderful description of your osteopathic evaluation caught my eye reflecting your talent, mostly, at this stage of your training.

I would like to support the excellent blog of you and your colleagues and be a resource since these are in such short supply, in the OMM-expertise area. I've made an excellent living for 20 years in private practice and been offered a chairmanship at one of our schools. I've taught cranial osteopathy for over ten years and completed postgraduate training in FP and a year of pediatrics. I've read misinformed views opined by students on blogs that saddened me and would like to contribute, based on my experience.

What is most important, and almost impossible to find in many parts of the country, is SUCCESSFUL, EXPERIENCED, WELL-TRAINED OMM practitioners CAPABLE OF TEACHING for students, residents and young practitioners and willing to enter into mentoring relationships. Also STUDY GROUPS run by same to provide the minimum foundation for trainees to acquire the skills necessary to practice OMM as a specialty. Using this approach, my Group and I have gone from 2 to 10 FT OMM practitioners in our region over 12 years.

We need OMM specialists, as well as those capable of integrating OMM into allopathic disciplines, and even allopathically-oriented DO's to interface with government and MD academia. They serve the profession well if they remain open-minded. This only occurs through personal and observational experience demonstrating the efficacy of OMT. We even need the non-believing PhD in our schools to provide rigorous debate. They should not have been hired if they are emotional and antagonistic (often due to the failure to initiate them into the osteopathic paradigm by allowing them to see OMM with their own eyes). It is the duty of your generation to integrate OMM into allopathic training; ours was to promote and salvage it from neglect and my teachers was to spread it around the world. You are precisely on track.

No one gets there without help in this work. The foundational curriculum is pretty good in OMM but the faculty is usually lacking. After the first two years students are on their own and just making what limited resources the profession possession available to students remains a major challenge. Most of our leaders fail to understand the impact of cranial osteopathy in particular at present. It is a force internationally and also at home, at the non- and paraprofessional levels. But the schools cannot effectively teach it lacking both the faculty and the political will to change it. We are still at the stage where dynamic individuals with drive, talent and vision must lead by example.

As to your progression so beautifully described in your blog i would suggest you persist with the basic standing flexion and motion palpation tests as time permits. The perceptual abilities you allude to are unreliable for final dx. Difficult cases always require us to fall back to some previous level of understanding to continually validate and verify our diagnostic impressions. The first step in ost. dx is observation, the second is palpation for position and finally special tests for motion (Ann Wales, DO). Sutherland said to, "get as far away from our physical senses as possible...", and that the art in osteopathy is that of a "Knowing diagnosis" (capitalization his own). He also advocated tactility in palpation e.g., the purpose of palpation of the transverse and spinous processes is to ascertain the position of the vertebral bodies through a projected sense of touch. The transformation that mystifies you must be a cornerstone of your professional life, never stop training and learning! I hope this is helpful.

Chris Laseter, DO

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